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What I have learned from this—there are three ways to live:  here, following the unavoidable facts like a religion; there, hoping for a miracle and living on luck; neutral, all those small lost souls in between.  We are neutral.  Before time can be complete we must learn our boundaries and conquer them.  Knowledge is divided into half, intelligence and wisdom.  With wisdom we can find our boundaries.  With intelligence we can conquer them.  We won't do these ever, but maybe we can try.  The more we learn the longer we can ask questions.  Another step.

I learned it from my patients, from my teachers, from my colleagues—and especially from my own children.  I found it expressed by Homer and Plato and Aristotle.  I read it in Hippocrates and in Leviticus.  God willing, I will find it in my own soul for my own sake, to be willing to be a patient so that I may live beyond the obstacles to living which belong to my life.

If I seem romantic or mystical, it is not so.  I am only who I am, knowing there are no pat answers--but there are ways.  “The answer” is only a way to fall off the road, a way to stop cold the ongoing dialogue of living.  If we jump to conclusions we may stop our progress.  Who we are can be translated into public policy only as we gain focus, integrity, health together.

Before we can assess costs we must own values, not in utopias, but in human reality.  Clinical values are only personal and cultural  responses to human mortality.

Polarizations blind us to being who we are, dancers on the tight-wire.  To go too far any direction may do us in.  Concretely, I propose simply that how we treat each other in pain and powerlessness tells us how well we are or are not together as a community of persons.  How we are has many facets:  to attend to the seeming self-interest of any one party or any one level renders us worse than a school of  sharks  carnivorously cannibal

We need to make it safe to answer yes, not to forget each of us is human, mortal, suffering, and that it is not out of power we respond, but from within our humanness.

I,  earthbound and concrete,  answer you by asking, “What will you do?"  You wonder why I ask, hoping I am the expert, an authority on what I have criticized.  I remind you I have experienced the important aspects of living no more than you have.  But I will tell you what I think will help.

If we forget the real need each patient has for personal attention and response we will lose the intrinsic value of the clinical enterprise.  If we respond to the patient's needs out of superstition, self-defensiveness or predetermined dogma, we will hurt him.

If we structure public or institutional financing of health care to narrow standard diagnoses  (when our  real lives and our real sufferings are unique and idiosyncratic) we will have excluded health care, whether purposefully programmatic or inadvertent.

Therefore, I suggest society exploit the altruism of traditional health professionals who respond around the clock to persons as patients, before all those craftspersons die off or are trained away from competence.

Skills in diagnosis and treatment have been accomplished by many clinicians within our culture.  We punish them now, more severely the more responsive they have each become.  Already they have been trained out of the ability to pursue a dialogue with the person who is patient.  This deficit is yet corrigible.

Today is the crucial time.  Let bureaucratic standards and corporate self-interest multiply, and almost immediately there will be no art or science in health care, much less the poetic harmony we miss in our bodies and in our souls and in our living.

The poor simple-minded country doctor is not nothing--she is I, struggling to stay in this human community.  We never miss her unless we ail.  She belongs to us tenuously as our access to comfort or healing.  If we are to have a better way, someone should tell us how it can be coherent if it is not configured through the doctor, the nurse, the pharmacist, the midwife, our culture's scribe, the reader of the story of my body and the experience of my very human life.

Our culture taught the clinician to overcome the fear of death and disease so that we each could have a calm consultant when we faced those threats.  Then our society and economy taught clinicians to specialize, to withhold communication from us as patients, to become preoccupied with technical  facts instead of human truths.  Now government punishes clinicians and the settings within which they work, but government policies aim for short-term political gains for politicians instead of long-term social and health gains for the community.

As patients we need to become competent health consumers.  We cannot accomplish this by weighing one health insurance plan against another, but by finding clinicians who make sense to us personally.

As clinicians we must remind ourselves what are our basic human tasks, not allow ourselves to be overwhelmed by technologic and bureaucratic demands, but to pay attention to each patient. We are our community's human resource in the deepest sense, the comforters of human mortality and vulnerability.

Complex health institutions (in which we all participate) must make room for and support the human aspects of health care not only by maintaining settings within which it can take place, but by using institutional influence to counter the disruptive measures government and the insurance industry have imposed.  Health care institutions must lobby actively for the politically punished and powerless humanist clinician even while they pursue their commercial enterprises.

Politicians and bureaucrats have difficulty producing good here.  Even when they mean well, because they are outside the consulting room they can add little to the human aspects of health care directly.  Their efforts to cut costs have multiplied costs not only on the budget ledger, but in the outrageous expenses of monitoring and controlling what cannot be monitored or controlled.  The result is the crushing of the human clinical relationship.  Government should back off from intruding on us as patients as far and as fast as possible.

Some may fear that to back off of government programs abruptly will leave unregulated a crucial part of our society and economy.  But these are the same parties who promote commercialization of health care, claiming free-market competition will reduce costs or increase benefits to persons or to society.

Such arguments are at the very least nonsense; or perhaps worse, they are intended for the sake of profit and power to distort or exploit the effects of illness on the lives of our people.  There is no real concern or action for the sake of the poorest and most profoundly suffering, nor is there concern for others beyond the cutting of costs to the healthy and wealthy.

As I have shown, the only promising method of improving the quality and the economy of health care in our society is to make available to each of us persons who are clinicians.  Techniques and facilities never once told a patient what he suffered, what his choices were, nor comforted him loyally through illness nor through health.  It takes a person to attend a person, and that clinician's reward will always be moral more than material.  Let us at least allow clinicians to pursue their altruistic motivations without punishing them for society's chaos.

Economy and efficiency likely will come only from radical and abrupt upending of the current health care structure.  We have within reach a system of universal, single-payer, not-for-profit health care with a personal “medical home” for each one in our community.

In previous chapters we have repeatedly confirmed some basic postulates:
A person becomes a patient out of fear.
The patient’s condition makes him dependent.
The patient is not responsible to comprehend or master her own condition.
Each clinician also is a person, no matter how complex the clinical team.
The clinical relationship, then, is personal and based in trust.
What is to be done is for the sake of the patient, though others may indeed benefit.
Clinical goods offered are diagnosis, treatment and prognosis (as in Hippocrates’ day).

All important clinical considerations derive from such as the above-outlined basic considerations, though there is a very broad spectrum of phenomena in the ever-changing real lives of patients.  No two patients need present in the same way; no one patient need present in the same way twice.  Yet we must find the basic common resources and services all patients need, and as a community make available infrastructures of clinical setting, training, coordination and underwriting.

We have shown what is needed is personal, trustworthy, altruistic and rational.  We have shown the patient is not so simple, is intimately connected with family, work, community.  We have shown that the clinical team is complex and often extends many miles away, beyond the view of the patient.  We have shown that the processes of diagnosis, treatment and prognosis always rely on effective communication at a personal level.  We have shown that distraction of focus away from the patient always will occur if we mix in other concerns like the financial wishes of the clinician or clinical institution, cultural biases, or demands coming from outside the clinical relationship.

One day some time after World War II, suddenly and overnight the American people demanded a change in the health care system, panicked at the increasing costs of health care.  We blamed the greed of doctors.  We deeply were convinced that big business was the exemplary model and mechanism of efficiency, so we sent out the mandate for big business to take over health care.  Entire new industries and professional disciplines were created to fulfill our mandate, immensely huge and expensive corporations, guilds, regulatory agencies.  None of these contributed to the clinical processes we have outlined in this study; they didn’t help a single patient.   What big business did was the only thing it is aimed to do, to control the market and to take for itself the profits thereof.  In tedious detail we have shown above the simple ways our culture and economy have compounded cost and waste in health care, and we have shown why the quality and distribution of health care have utterly disintegrated like sand through our fingers.

I say a change happened overnight, and with regard to our American consciousness it did.  We were conscious of the rising costs and we were conscious of our faith in competition in the marketplace.  We were not conscious of what all the rest of the world was doing to accomplish reliable and affordable health care.  As we often had done (and sometimes bludgeoned our way into some semblance of success with), we stubbornly forged ahead on the basis of our idiosyncratic political assumptions, forgetting that our politics is based on sales competition rather than on service to the community.

Corporations may per se not be evil or destructive, but their underlying motive is always profit rather than service.  (It may be that what are called non-profit corporations are intended to serve, but even they often compete for power or influence, or are shells for profit-making concerns to minimize their tax responsibilities.)  Similarly, political competition on some level sincerely may be intended to accomplish public good, but inevitably we seek that public good through profit- and power-grabbing rather than through cooperation and reason.  What has all this to do with attention to the sick and poor?  What has it to do with the promotion of health?

The costly flaws of our disintegrating health system come not alone from the profit- and power-motives of corporations or of health professionals, but from perturbations spun off from those profit motives.  Conscious and conspiratorial on the one hand, or unintended and inadvertent, these disjunctions lead not to improvement or resolution of an ailing person’s health problems, but instead tend to perpetuate and compound those problems, to recycle them into ongoing sales accounts in the commercial system (until all resources or credit are exhausted).

The first obstacle to health care in our profit-oriented system is that you cannot get care unless you have resources with which to pay.  The uninsured have no resources with which to pay.

Corporate or clinical specialists’ refusal to cooperate with competitors results in reduplication of expensive and risky procedures and services.  When my problem as a patient isn’t resolved in one setting, procedures meant to clarify or relieve that problem are reduplicated or contradicted in the next setting, adding to confusion rather than to clarity.  I don’t so much need a second opinion as I need a careful and reliable first opinion.

Fragmentation of services and of communication results in confusion beyond my ability as a patient to comprehend; that confusion further camouflages my problem, obstructs the solving of it.  Now no one clinician can make sense of the results of my several reduplicated diagnostic procedures, nor comprehend my multiple medications from multiple prescribing sources.  If one clinician cannot understand and communicate to me what is up, I don’t know that I want to submit to a committee instead1

Miscommunication, sub-specialization, advertising, false promises and false expectations distract us from focusing on the real patient.  Education and research long since have become marketing tools, property of the corporations, because attention to profits has replaced attention to patients.

Sub-specialization seems like a more microscopic lens through which to scrutinize the patient’s problem, and well should be, and often is just so.  But the more we act focused upon a detail, the more easily we can be distracted from the whole (“can’t see the forest for the trees”).  It may take a primary clinician to execute the referral to a specialist (or increasingly today, the patient herself chooses such specialists), but to whom does the feedback come?  Who can make use of the specialist’s contribution?  Who can try to ask the initial question coherently, and who can make sense of the answer?  Too often the specialist is satisfied to have collected the fee.  Effective communication with the primary clinician or with the patient is increasingly rare, so consultation too often is of little use, or even has negative effects (e.g., recommendation for unnecessary or risky procedures).

“Caveat emptor” is worse than useless to me as a patient.  I have no way reliably to choose what is good for me, only to choose among the many who are hawking it to me on the television.  I cannot do technical research to make life-and-death choices while I am comatose.  Rather, I must have someone I can trust, but there is no one I can trust.

False expectation of high technology is all but universal in our culture.  Elaborate and expensive new tools and molecules are fine for what they are fine for.  But our deficiency is in basic (not high-tech) tools currently withheld not only from the poor but from the rich (who go to other countries for high-tech care at more reasonable prices).  The rich can no longer for any price get coordinated personal health care here.  If they pay their own physician enough they may be able to buy that person’s attention, but the health care system around them is disintegrated (as we have outlined in all the foregoing), so protection from confusion, reduplication and error is not possible; and coordination of care through that attentive physician is either unavailable or at least tenuous (ask her how difficult it is to accomplish).

From the inherent mythology of big business (“caveat emptor”), it follows that expensive and risky health care choices must be made through advertising (through your television set).  At a previous time drugs were prescribed by licensed professionals who had been trained, examined and licensed by a regulatory agency of that state; now they are prescribed by television and internet.  I am not jealous for the business, just horrified for my patients’ sakes.  Untested and not scrutinized by federal agencies (which thereby silently countenance the scams) over-the-counter drugs and supplements are peddled with the clear implication they have been approved by somebody important and reliable but they have not.  Clinics and clinicians, hospitals and corporations, purveyors and providers of equipment and technologic gadgets have been coerced by “market forces” not merely to be listed in classified telephone directories and the internet (in terms of claims rather than facts), and take out full-page color ads, billboards, mass mailings and all the other tree-killing and billions-wasting modalities of commercial persuasion.

Clinical research and education have become marketing tools completely controlled by drug manufacturers.  “Continuing Education” courses for professionals do not educate; rather they very often promote particular commercial products.  There is some attempt by clinical organizations and institutions to reverse this, sheer spitting into the wind.

Political compromise is our usual American method of seeking change, but that will always revert to stagnation.  It clearly is so with regard to health care.  It appears so far that no matter what we do, it backfires.  DRG’s (diagnosis-related groups) was an early proposal for a statistical research tool to assess some health care expenditures and outcomes.  This method was instead prematurely usurped by the insurance industry (which includes the new federal bureaucracy of healthcare management), converted into grouping expensive procedures together (“bundling”) so the charges for those procedures and the hospitalizations occasioned by them could have fixed prices (to keep hospitals and physicians from padding their bills by prolonging hospitalizations and adding unnecessary procedures).  DRG’s instead resulted in drastic reduction of hospital days, often at the cost of health, comfort or even the very life of the patient—and untold billions pocketed by insurance companies whose premiums had already been received, but claims against whom are reduced or outright denied.

HIPAA (The Health Insurance Portability and Accountability Act of 1996) was intended to protect insurability for employees and to protect confidentiality for patients.  The health insurance portability aspect was gutted before its passage (remained merely as a title of the bill, acronymically—health insurance was not made “portable” from job to job).  For clinicians, confidentiality needed no new legislation, as their ethics and the extant laws and regulations (if only they were utilized) already were satisfactory to effect that protection.  The only additional protection intended in HIPAA was from insurance companies raiding medical records to exclude coverage, to deny claims from those who had already paid premiums.  (Those who had not paid premiums couldn’t make claims anyhow.)  Needless to say, insurance companies are powerful enough and rich enough to buy confidential information despite any laws, so they manage to deny payment wholesale none the less.2  Over half the rapidly increasing number of personal bankruptcies of recent years are directly due to medical bills beyond the capacity of the patient to pay, many who had already paid for health insurance.

Even the most skilled and altruistic clinician cannot do good work in such a context.  A clinician cannot make a living without sacrificing altruistic focus on the needs of the patient, silently joining in the profit-driven mechanisms of the health care industry.  The simple clinical task is to offer attention, decision and action for the sake of and in communication with the unique patient.  Economy can come only from attending to the task.  (Ask any third-grader.)  Instead, with increasing intensity here we have a rush toward procedures, substances and institutions, commodities promoted loudly in the marketplace.  We ignore that when I am sick, frightened, poor, confused, ashamed or comatose I cannot make consumer choices.  I assure you these are not consumer choices to be manipulated for profit, but life-and-death matters to be respected with awe.

Now we can ask what it is the reasonable third-grader will recommend.  First of all, since the whole thing seems to have gone cattywampus on us, we well might look for abrupt and radical change.  (In the face of such an imbalance of the power of greed versus the value of care a “gradual” change is certain to be no change whatsoever.)

In light of what we have learned here, and in light of my experience throughout the past six decades, the one thing we need most is healing through meeting.  What I mean by this is reestablishment of the personal health care relationship (fiduciary) rather than the other-than-personal relationship which excludes the patient (even as consumer) and also excludes the person who is the clinician.  That impersonal relationship is between non-persons--corporations (public, private, large, small, formal, informal)—a strictly fiscal relationship.

Our first clinical task is to make sense of the basic questions (“What seems to be the problem?” and “What shall we try to do about it?”).  A next task is to do what is required to clarify these questions.  Throughout the processes it is necessary to communicate continuously effectively (personally) with the patient (which usually also means with the family or the patient’s intimate community).  This is what professional organizations of primary clinicians mean by “personal medical home” for each citizen.  It is the most economic approach since it can minimize reduplication.

As we have seen, with regard to procedures, drugs and billing, reduplication results from the profit motive of corporations and of the clinicians who almost universally are in their employ (formally or informally).  To remove the profit motive in health care delivery does not mean the exclusion or impoverishment of health professionals (including “support staff”) or the exclusion of those organizations which allow them to work effectively and efficiently.  Removal of the profit motive allows focus on the only valid goal, the welfare of the real patient and of the community within which she lives.  Transition away from profit motive (and to fair and generous valuation of productive promotion of real health care) will and should be radical and abrupt; but it will be smoother than anyone today imagines because siphoning off of resources will be minimized and improvement of good care will be immediate.

“Single-payer” does not mean single-payer so much as it means single-processor.  Every one will be treated fairly and openly.  The processing of claims takes about thirty per cent of our health expenditure.  Even though such a change in the structure of health care will save immense amounts (trillions), the main advantage will be that each claim will be treated as each other.  The rules will be uniform for each patient, and patent rather than arcane.  A single processing organization for payment will be free of the need to extract a profit in dollars rather than health, to refuse payment for appropriate services, to camouflage the basis of judgements, to reduplicate expertise and expense in hundreds of processing organizations (thousands of offices), nor to wallow in hugely expensive competition which takes place on the television set your children are watching right now.  Those expert and skilled at health care administration will certainly have well-paying jobs in this huge project (more huge because it will include the fifty million who now have no reliable health care and the tens of millions now losing their jobs and coverage).

It is very expensive in lives, suffering, worry, shame and dollars to allow persons in our community to fester without care.  For the sake of the patient’s welfare and the community’s resources we can maximize autonomy, minimize dependency, enhance productivity, reestablish disease-prevention and health education, and reduce net dollar expense by making health care universal, excluding no one.

This simple set of readjustments will work only if is radical and abrupt.  Compromise will guarantee rapid reversion in all these critical areas.  Short-sighted self-serving politicians and lobbyists will do what they have always done, make excuses about “cost-cutting” by excluding the sick and poor; they will proliferate competition in the marketplace which feeds them personally, sell privileges to siphon off resources into the pockets of those who pander to them, and make us believe the needs of health are served by massive business organization and “new” technology and drugs.

I apologize for stating these simple ideas in polysyllables (for my education has rendered me verbally challenged).  Our third-grader consultant might say something like this:  “Take care of everyone before they get sick or sicker.  Do it because it is good to do.  Do it well so you don’t have to do it over and over.  Then you can do it for others and more others.  Don’t worry about being paid, because if you treat us nice we will treat you nice.”


1 “A camel is a horse designed by a committee,” which I long considered to be Mark Twain’s, is better attributed to Sir Alexander Arnold Constantine Issigonis, CBE, FRS (November 18, 1906–October 2, 1988) Greek-British automobile designer best known for the Morris Minor and the Mini Cooper.

2 The demonstrations of the documentary movie “Sicko” may appear sensational, but they are accurate.

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